Provider Demographics
NPI:1093775744
Name:CHAKOS, MIRANDA
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:CHAKOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4611
Mailing Address - Country:US
Mailing Address - Phone:718-270-1748
Mailing Address - Fax:
Practice Address - Street 1:5131 RIVER CLUB DR STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3837
Practice Address - Country:US
Practice Address - Phone:804-207-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010539012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20H872Medicaid
NY20H872Medicaid